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Application of the assessment process with an individual with a physical disability

This is an excerpt from Recreational Therapy Assessment by Thomas K. Skalko & Jerome Singleton.

By David P. Loy

Case Study

Application of the Assessment Process With an Individual With a Physical Disability

Bill is a 26-year-old with C6 quadriplegia. He completed three months of physical rehabilitation and has been living in the community with his wife for the past nine months. Bill heard about the recreational therapist working in his community and met with her to gain more independence and become more active since his discharge. Sarah Bellinger, a CTRS working in Bill's community, agreed to meet with Bill to conduct an assessment. She asked Bill if he could access his inpatient rehabilitation records or have them transferred to her in order to provide some preliminary information. During the initial meeting, Sarah performed a battery of assessments. She used a recreation interest survey to assess Bill's preferred recreation and leisure (d920) activities, a hand and finger dynamometer test for fine hand use (d440), the WST for mobility (d498), the CHART for community reintegration, and the modified functional reach test for vestibular balance (b240). The information indicates Bill has had limited recreation engagement (d920) since his SCI but expressed interest in sports and exercise (d9201) with a desire to get stronger so that he can progress from his power chair to a manual wheelchair. He has expressed a small fear of going in the community by himself because he doesn't have confidence in his skills. Hand and finger dynamometer readings indicate below average fine hand use (d440), but appropriate considering his spinal cord injury level. The WST test indicated a score of 19 (out of 66) for mobility (d498) and the CHART scores ranged from 18 to 32 in all five areas of CI. Answer the following questions based on this information.

1. Discuss how the diagnosis of an SCI may have affected the CTRS's selection of assessment instruments.
2. What are some appropriate treatment goals based on the interpretation of the assessment performance data provided?
3. What are some preliminary interventions appropriate for Bill based on your interpretation of the assessment results?

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